Author + information
- Jian-Fang Ren, MD∗ (, )
- David J. Callans, MD and
- Francis E. Marchlinski, MD
- ↵∗University of Pennsylvania Health System, 111 North 9th Street, Philadelphia, Pennsylvania 19107-2452
We read with interest the review paper on paradoxical embolism by Windecker et al. (1). It was suggested, on the basis of available evidence from published reports, that device closure of patent foramen ovale (PFO) should be considered in patients with first-time cryptogenic stroke, particularly in those with high-risk criteria, such as presence of an atrial septal aneurysm (ASA), large PFO, Eustachian valve, or Chiari network. The viewpoints of Windecker et al. on those with high-risk criteria should be discussed and clarified.
With routine clinical application of intracardiac echocardiography (ICE) in more than 3,000 cases of left heart ablation, it has been proven that ICE is an excellent ultrasound modality that can be used for diagnosis of an ASA, PFO, variant Eustachian valve, or Chiari network (2). A statistical analysis of 938 consecutive cases with left heart ablation from 2012 to August 2014 showed that the incidence of ASA was 6.9% and the incidence of PFO was 6.4%. A variant Eustachian valve or Chiari network in the right atrium is more commonly detected by routine ICE. Generally speaking, ASA without a septal defect and probe PFO should not be considered forms of an atrial septal defect and are benign. By themselves, they cause no hemodynamic abnormalities. A previous case report (3) showed a small PFO (diameter of <4 mm) with left to right shunting (Figure 2E in the review by Windecker et al. ) and a transseptal sheath for hemodynamic support with a left ventricular assist device (the TandemHeart) (3). An iatrogenic PFO with large sheath placement at the interatrial septum is commonly detected with ICE monitoring (Figures 1A and 1B). In the case report (3), the conclusion of “death by PFO” remains questionable. Iatrogenic PFO (<4 mm) might not be excluded, even in Figure 3 in the case report (3), with a small/weak right-to-left shunt flow (not mosaic color pattern) accompanying the transseptal sheath. A small PFO could not explain that particular case, in which deep left femoral vein thrombosis and bilateral subsegmental pulmonary embolism advanced to myocardial embolic infarction.
We disagree with the viewpoints of Windecker et al. (1) on device closure in those with high-risk criteria, including an ASA, PFO, Eustachian valve, or Chiari network. We particularly dispute the idea that a prominent Eustachian valve would direct blood from the inferior vena cava toward the PFO; our figure (Figures 1C and 1D) suggests that this is not the case. ICE color Doppler flow imaging is superior to transient imaging with injected bubbles. The same applies to the Chiari network in the right atrium with chaotic motion (Figure 1E). Therefore, device closure should not necessarily be considered in patients with first-time cryptogenic stroke who have these benign variant anatomic abnormalities.
Please note: Dr. Marchlinski has received research support and served on the advisory board of Biosense Webster Inc., but this relationship is not relevant to the contents of this letter. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- American College of Cardiology Foundation